Central American Woman with Influenza and Severe Weakness

Chief Complaint: Cough and fever
Central American middle age woman presented on January 11, 2011 to the outpatient clinic with one week history of cough and fever up to 101 deg F. She denies chills. She also denied much in the way of sputum but complained of some headache. She was diagnosed with right lower lobe pneumonia and begun on albuterol aerosols and levofloxacin orally.

On January 14th she came back to the clinic complaining of dysgusia and increasing sputum production. She felt “her sputum was loosening up.” She noted that her fever lasted 7 days. She also complained of feeling inordinately weak. She denies chest pain or changes in the color of the urine.

On January 24th she returned for follow up to the clinic. At that time she was regaining her appetite but felt increasing weaker. She denies fever or discoloration of the urine. Her physical exam revealed a slightly disheveled middle age woman without tenderness in the major muscle groups. Her chest exam was remarkably clearer.

A laboratory study was performed on this day that led to calling her back immediately to be re-evaluated.

Middle age woman with uncontrolled DM type 2.

62 year-old woman is seen for uncontrolled type 2 diabetes mellitus of 15 years duration. She brings her fasting and postprandial glucose levels. Her HgbA1c is 9%. Her fasting glucose levels are of the order of 120 to 150 mg/dl. Her postprandial levels are 200 to 300 mg/dl. She has no health insurance. She pays 50 dollars per month for her vial of Humulin 70/30 insulin. She injects herself 50 units in AM and 40 units in PM. Her C peptide is 2.
What is your recommendation on how to control her diabetes?

48 year-old with abdominal pain and distencion

Chief Complaint: Abdominal Pain
A 48 year-old man presented to the outpatient clinic with a 3 day history of mid epigastric pain. There was no vomiting but some nausea. He denies fever. Questionable history of some diarrhea 3-4 days prior but since then little in the way of bowel movement. On the morning when he was seen he did have a formed bowel movement. Denies weight loss, mucous in the stools or travel recently abroad. Denies peptic ulcer disease.

There is a history of beer drinking often, questionable excessive. No history of liver disease.
On exam, he appeared somewhat distressed because of abdominal distension and pain. He was afebrile. The blood pressure was normal, the pulse 95 regular and the reparations 22 per minute. The chest was clear but shallow. The heart without murmur orgallop. The abdomen was distended, minimally dystehrmic and without point tenderness. On auscultation there was hyperresonance at the epigastrium.

A flat and uprioght set of films of the abdomen are shown.

Where do we go form here in diagnositics and management?

Presented by Dr A Gordon

Recurrent bronchospasm a middle age man

46 year old male presented for follow up to the outpatient clinic because of severe flu-like, asthmatic symptoms. The patient is concerned that in recent times, during the last year, he has been battling recurrent repiratory infections. He now "remembers" that as a child he used to suffer form episodes of bronchospsm and shortness of breath with exercise. He is now susceptible to just anything in the environment. His airways are very hypersensitive. What are you thinking about in your diagnositc approach and therapy with this otherwise healthy and corpulent man?